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Credentialing & Enrollment Services

Provider Enrollment and Credentialing Services

Physicians/providers must credential themselves, which entails enrolling in and attesting to the Payer’s network and being authorized to deliver services to Payer’s plan participants. The credentialing process checks that a physician’s education, license, experience, certifications, affiliations, malpractice, any adverse clinical occurrences, and training fulfill the Payer’s criteria for delivering clinical care.

Physicians who are not certified and enrolled with a payor may have their payments delayed or denied. This has a negative effect on the practice’s finances. Our Payer credentialing and enrollment services are tailored to help physicians in the following areas:

  • Starting a new practice or joining an existing one.
  • Changing from one group of physicians to another.
  • Join or associate with new organizations or practices.
  • Enroll new customers.
  • Continue to provide certification services.


Provider Credential Services

The steps in the procedure are as follows

  • Application Evaluation – Completing the necessary paperwork and noting any exceptions.
  • Primary Source Documentation – Physicians should be contacted to verify practitioner/facility information.
  • Outbound Call Center – Obtaining missing papers and updating the payer’s database are both tasks that must be completed.
  • Follow-up with payers – Follow up on credentialing requests that have been submitted.
  • Data Entry – Data should be captured, labels should be applied, and photos should be linked to specific providers/facilities in the payer’s database.
  • Maintenance of Provider Data – Provider information should be updated in accordance with policies and procedures, as well as the HQ profile.


Provider Enrollment Services

Our Provider Enrollment services help practices get registered for the services they offer by ensuring that payers have the information they need to process claims for those services. We keep a close eye on the payers to guarantee that applications are received and handled in a timely manner. We work hard to spot and fix any potential administrative issues before they have an impact on your provider reimbursements.

The steps in the procedure are as follows:

  • Verification of provider information – Before we submit claims, we check with payers to see if they have the correct provider information on file.
  • Updating practice’s Pay-to address – Validate and update the pay-to or billing address of the provider.
  • Enrolling in electronic transactions – Our staff can sign up providers for the following four types of electronic transactions:
  1. Electronic Data Interchange (EDI)
  2. Electronic Remittance Advice (ERA)
  3. Electronic Fund Transfer (EFT) and
  4. CSI

Provider Enrollment and Credentialing Services — We can assist you with:

  • Provider enrollment and credentialing with commercial payors such as Aetna, Anthem, Cigna, Humana, United Healthcare, BCBS, and others) – State and Drug Enforcement Agency (DEA) registration or renewal
  • Enrollment, credentialing, and revalidation for Medicare and Medicaid – License renewals, Board Certificates, Malpractice Insurance, and so on. – Attestation by CAQH.
  • Creating and managing practitioner contracts, as well as adding/removing practitioners from existing contracts and negotiating rates.
  • PECOS. 
  • NPI (National Provider Identifier) registration (both Type I and Type II).


Our Provider Enrollment and Credentialing Services have a number of advantages.

The following are some of the advantages of using our thorough provider enrollment and credentialing services:

  • Obtain credentialing with all major payers in a shorter period of time.
  • Improve cash flow by lowering claim denials.
  • The network can help you get more patient recommendations.
  • Using our document management solution, you can avoid heaps of paperwork.
  • Obtain assistance in completing lengthy application forms.
  • With our worldwide delivery teams, you can lower the cost of credentialing.
  • Get status updates on your applications in real-time.


Our Credentialing Services for Providers Involve

Provider Data Maintenance – Update Management on Payer Systems

  • In the payers’ file, there is an update to the provider’s demographics. (Additional educational credentials or updates to the Provider’s specialty)
  • Maintaining the provider list on payer websites. (Visiting the payer’s website and confirming provider information such as phone and fax numbers, as well as zip code.) Payers are being notified of the correction.)
  • EFT/ERA enrollments.

Creating and Maintaining Contracts

  • Contracts for individual and group practitioners are now available.
  • In an existing contract, adding or removing providers is possible.
  • In the present contract, adding/removing a location.
  • In the existing contract, you can add or remove plan types (Line of Business).
  • Negotiating the price.

CAQH Attestation

For credentialing, directory maintenance, benefits coordination, and other important business operations, the Council for Affordable Quality Healthcare, Inc. minimizes duplicate and inefficient administrative processes between health insurers and providers.

  • The application for CAQH has been submitted.
  • Attestations by the CAQH on a quarterly basis.

Renewals and Expirations

The state DEA license, board certificate, and malpractice insurance expiration date are all being tracked.


Tracking and Analytics

  • Maintaining a collection of certification documentation for providers.
  • Contractual agreements must be kept up to date.
  • To begin credentialing processes, keep track of credentialing dates, expiration dates, and alerting dates.
  • Working with the rejections team to determine if any claims have been denied due to credentialing difficulties.